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Informal Clinical Integration Associated With Lower Surgical Care Spending


With formal integration initiatives, such as accountable care organizations, having modest effects, researchers analyzed the impact of informal clinical integration on cardiac surgery payments and found that patients who were treated in health systems with higher informal integration had greater savings.

Informal clinical integration among primary and specialty physicians is associated with lower spending in surgical care, according to a study published in JAMA Surgery.

With the varying costs of surgery across health systems, many have identified the fragmented nature of surgical care delivery as a culprit.

“Suboptimal coordination among clinicians around the time of the surgical episode can affect healthcare spending by increasing the likelihood that clinical care team members provide duplicate tests, treatments, or services,” wrote the authors of the study. “Fragmentation also impedes the ability of physicians to identify imminent postoperative needs of patients after hospital discharge, resulting in emergency department visits and readmissions to the hospital.”

To address this fragmentation, payers and providers nationwide have been teaming up and collaborating through initiatives such as accountable care organizations (ACOs) and the patient-centered medical home, which promotes and underscores the importance of clinical integration among physicians.

However, with modest results of organizations like these, the authors point to formal integration as a weakness and argue that informal integration may have greater positive impact. To study the effects, the authors analyzed surgical episode payments for 253,545 Medicare beneficiaries undergoing coronary artery bypass grafting procedures from January 1, 2008, through December 31, 2011.

Interactions were mapped between all physicians who treated the patients during their surgical episode, including primary care physicians and surgical and medical specialists. Interactions between physicians if they billed for the same beneficiary were documented, and multivariate regression models were fitted to evaluate the association between payments for each surgical episode made on a beneficiary’s behalf and the level of informal integration in the health system where the patient was treated.

The low level of informal clinical integration included 84,598 patients, the medium level included 84,442, and the high level included 84,505. Health systems with low and medium integration were more likely to have patients with comorbid illnesses and more patients from urban areas. They also had more physicians, more physicians who were geographically dispersed, and were less likely to use electronic health records, which suggests that health systems that treat more disadvantaged populations tend to be less informally integrated, according to the authors.

When patients were treated in health systems with higher informal integration, the greatest savings of lower estimated payments were from hospital readmissions (13%) and postacute care services (5.8%).

“These results support the idea that better informal integration of physicians during surgical care may improve patient coordination and lead to greater efficiency,” the authors wrote.

According to the authors, there are several implications from the study. First, the findings suggest that health system administrators and policy makers may benefit from viewing formal and informal clinical integration as 2 distinct phenomena. The findings also suggest that the possibility that informal integration may contribute to the success or failure of formal programs aimed at reducing fragmentation. Lastly, their index of informal integration may prove useful for health system administrators and researchers.


Funk RJ, Owen-Smith J, Kaufman SA, Nallamothu BK, Hollingsworth JM. Association of informal clinical integration of physicians with cardiac surgery payments [published online December 27, 2017]. JAMA Surg. doi: 10.1001/jamasurg.2017.5150. Accessed February 22, 2018.

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